Provider Demographics
NPI:1295196152
Name:BRENNAN, EDWIN (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:
Last Name:BRENNAN
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FORT POLK VA OUTPATIENT CLINIC
Mailing Address - Street 2:3353 UNIVERSITY PARKWAY
Mailing Address - City:LEESVILLE, LA 71446
Mailing Address - State:LA
Mailing Address - Zip Code:71446
Mailing Address - Country:US
Mailing Address - Phone:373-392-3800
Mailing Address - Fax:
Practice Address - Street 1:3353 UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-9041
Practice Address - Country:US
Practice Address - Phone:337-392-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014593101YM0800X
LA1544103TH0100X
103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health